Current practice in the management of Attention Deficit Disorder with Hyperactivity (ADHD)

Age at diagnosis and diagnostic delay across attention-deficit hyperactivity and autism spectrums

BACKGROUND

Despite the known benefits of accurate and timely diagnosis for children with attention-deficit hyperactivity disorder and autism spectrum disorders (autism), for some children this goal is not always achieved. Existing research has explored diagnostic delay for autism and attention-deficit hyperactivity disorder only, and when attention-deficit hyperactivity disorder and autism co-occur, autism has been the focus. No study has directly compared age at diagnosis and diagnostic delay for males and females across attention-deficit hyperactivity disorder, autism and specifically, attention-deficit hyperactivity disorder + autism.

METHODS

Australian caregivers (N = 677) of children with attention-deficit hyperactivity disorder, autism or attention-deficit hyperactivity disorder + autism were recruited via social media (n = 594) and the Monash Autism and ADHD Genetics and Neurodevelopment Project (n = 83). Caregivers reported on their child's diagnostic process. Diagnostic delay was the mean difference between general initial developmental concerns and the child's attention-deficit hyperactivity disorder and autism diagnosis.

RESULTS

Children with autism were significantly younger at autism diagnosis than the attention-deficit hyperactivity disorder + autism group (ηp2 = 0.06), whereas children with attention-deficit hyperactivity disorder were significantly older at attention-deficit hyperactivity disorder diagnosis than the attention-deficit hyperactivity disorder + autism group (ηp2 = 0.01). Delay to attention-deficit hyperactivity disorder and autism diagnosis was significantly longer in the attention-deficit hyperactivity disorder + autism group compared to attention-deficit hyperactivity disorder (ηp2 = 0.02) and autism (η2 = 0.04) only. Delay to autism diagnosis for females with autism (η2 = 0.06) and attention-deficit hyperactivity disorder + autism (η2 = 0.04) was longer compared to males.

CONCLUSIONS

Having attention-deficit hyperactivity disorder + autism and being female were associated with longer delays to diagnosis. The reasons for these delays and possible adverse effects on outcomes require further study.

School-based Screening to Identify Children At Risk for Attention-Deficit/Hyperactivity Disorder: Barriers and Implications

This report describes a school-based screening project to improve early identification of children at risk for attention-deficit/hyperactivity disorder (ADHD) and communicate these concerns to parents, recommending that they contact their child's primary care provider (PCP). Of 17,440 eligible children in first through fifth grades in five school districts, 47.0% of parents provided required written consent, and teachers completed 70.4% of the online screeners (using the Vanderbilt AD/HD Diagnostic Teacher Rating Scale). Of 5,772 screeners completed, 18.1% of children (n = 1,044) were identified as at risk. Parents of at-risk children were contacted to explain risk status and recommended to visit their child's PCP for further evaluation. It was not possible to contact 39.1% of parents of at-risk children. Of the 636 parents of at-risk children who could be contacted, 53.1% (n = 338) verbally accepted the recommendation to follow-up with their PCP, which was not related to ADHD symptom severity. Parents of children with IEPs or related services were more likely to accept the recommendation to visit the PCP. Our exploration of the potential for school-based screening for ADHD identified a number of barriers to successful execution, but the data also indicated that this is an important problem to address.

Single-dose effects on the P3no-go ERP component predict clinical response to stimulants in pediatric ADHD

OBJECTIVE

Approximately 30% of children and adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) and treated with stimulants are considered non-responders (non-REs). Reliable predictors of response are missing. We examined changes in Event-Related Potentials (ERPs) induced by a single dose of stimulant medication in order to predict later clinical response.

METHODS

ERPs were registered twice during performance of a visual cued go/no-go task in 87 ADHD patients (27 girls) aged 8-18years; the second recording on a single dose of stimulant medication, followed by a systematic medication trial lasting 4weeks. Based on the four-week trial, participants were categorized as responders (REs, N=62) or non-REs (N=25). Changes among REs and non-REs in ERP components (cueP3, CNV, P3go, N2no-go, P3no-go) and behavioral-test variables were then compared.

RESULTS

REs and non-REs differed significantly in medication-induced changes in P3no-go, cue-P3, CNV, omission errors, reaction time, and reaction-time variability. The largest effect size was found for P3no-go amplitude (p<.001; d=1.76). Changes in P3no-go and omission errors correctly classified 90% of the REs and 76% of the non-REs, when controlling for the age of the participants.

CONCLUSION

Clinical response to stimulants can be predicted by assessing single-dose changes in the P3no-go ERP component amplitude.

SIGNIFICANCE

Changes in P3no-go may be a clinically useful marker of response to stimulants.

Using Best-Worst Scaling to Measure Caregiver Preferences for Managing their Child's ADHD: A Pilot Study

BACKGROUND

Management of attention-deficit/hyperactivity disorder (ADHD) is a trade-off between caregivers' concerns about the benefits versus the risks of evidence-based treatment. Few studies have used choice-based methods to assess what treatment attributes matter most to caregivers.

OBJECTIVE

The aim was to develop and to pilot an instrument to elicit caregivers' preferences for evidence-based management of their child's ADHD.

METHODS

Mixed methods were used to develop a Best-Worst Scaling (BWS) instrument, and quantitative methods were used to pilot the instrument. Primary caregivers of children with ADHD from two community organizations were recruited for the development (n = 21) and pilot (n = 37) phase. The instrument was a BWS case 2, where 18 management profiles are presented one at a time, with respondents indicating the one best and one worst feature of each profile. Profiles were developed using a main effects orthogonal array. The mean of best-minus-worse scores was estimated, and attribute importance was based on the sum of maximum minus minimum scores for each attribute. Feasibility of eliciting stated preferences was evaluated with t tests and 95 % confidence intervals.

RESULTS

Seven attributes (medication, therapy, school, caregiver training, provider specialty, provider communication, and out-of-pocket costs) with three levels each were identified. All mean scores were significant except for pediatrician management of the child's ADHD (p = 0.089). Caregiver training had the highest relative importance, followed by medication and provider communication.

CONCLUSIONS

The BWS instrument was a relatively simple measure, caregivers completed it independently, and it distinguished the relative importance of different attributes in managing a child's ADHD.

Management of ADHD in children and adolescents: clinical audit in a South African setting

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) is common, yet under-recognised and undertreated, particularly in low socio-economic settings. Little is known about compliance to evidence- based guidelines in low- and middle-income countries, and no clinical audits have been published in Africa. We undertook to measure compliance in a South African setting using the National Institute for Clinical Excellence (NICE) guidelines for ADHD as the gold standard to compare compliance and socio-demographic characteristics between two treatment locations in Cape Town and to generate an audit checklist for standardising care.

METHODS

The study used a sample of 100 randomly selected cases of school-age patients diagnosed with ADHD, at the Division of Child & Adolescent Psychiatry, Red Cross War Memorial Children's Hospital and University of Cape Town, South Africa. Fifty cases each from a central and a peripheral clinic location were reviewed retrospectively using audit tools, including 17 audit standards derived from NICE guidelines. We defined compliance as "good" with ≥80%, "fair" with 50-79%, and "poor" with <50% adherence.

RESULTS

Compliance was low, with only four audit standards rated as "good". Physical monitoring was especially poor. The central group received more treatment options and relatively safer monitoring.

CONCLUSIONS

We recommend introducing structured protocols followed by re-auditing to improve service delivery, and present a checklist for use in future audit cycles.

Costs and treatment patterns of incident ADHD patients - a comparative analysis before and after the initial diagnosis

BACKGROUND AND OBJECTIVES

The costs and treatment patterns of attention deficit hyperactivity disorder (ADHD) are subjects of health services research in Germany and worldwide. Previous publications focused mainly on prevalent patients and thus research gaps were identified regarding costs and treatment patterns of incident patients before and after the first diagnosis.

METHODS

Analyses were conducted using claims data obtained from a large German sickness fund (Techniker Krankenkasse). Inclusion criteria consisted of patients with at least two secured outpatient or one inpatient ADHD diagnosis in 2007. Incidence was ensured by defining a baseline period without ADHD-diagnosis in 2006. In addition to diseaserelated cost analyses compared to a control group including age group comparisons, comorbidities, the proportion of multimodal treatment and medication treatment patterns were described.

RESULTS

In total, 9083 newly diagnosed ADHD patients were identified (73 % male; mean age: 12.9 years (SD: 10.3)). The mean total cost of ADHD patients during the year after the first diagnosis exceeded the mean total cost of the year before by 976 € (Differencein-Difference-estimator: 1006 €). Our analyses have shown that 10 % of ADHD patients have been treated with multimodal therapy. In addition, 11 % of the investigated ADHD population have received methylphenidate or atomoxetine preceeding the date of diagnosis in the relevant observation period.

DISCUSSION

This study provides important insights into the costs as well as the treatment patterns of incident ADHD patients. ADHD-related costs and medications can be identified prior to the date of the first ADHD diagnosis. Although, multimodal therapy is presented as an optimal treatment option by many international guidelines and experts, its proportion for treatment is low (10 %). Further research is necessary to identify reasons for the low proportion of multimodal therapy and (cost-)effectiveness has to be evaluated in comparison to other treatment options. In addition, ADHD-related costs could be identified before the first diagnosis is documented. The reasons for medication prior to diagnosis have to be further investigated.

White matter microstructure predicts autistic traits in attention-deficit/hyperactivity disorder

Traits of autism spectrum disorder (ASD) in children with attention-deficit/hyperactivity disorder (ADHD) have previously been found to index clinical severity. This study examined the association of ASD traits with diffusion parameters in adolescent males with ADHD (n = 17), and also compared WM microstructure relative to controls (n = 17). Significant associations (p < 0.05, corrected) were found between fractional anisotropy/radial diffusivity and ASD trait severity (positive and negative correlations respectively), mostly in the right posterior limb of the internal capsule/corticospinal tract, right cerebellar peduncle and the midbrain. No case-control differences were found for the diffusion parameters investigated. This is the first report of a WM microstructural signature of autistic traits in ADHD. Thus, even in the absence of full disorder, ASD traits may index a distinctive underlying neurobiology in ADHD.

Physical and neurodevelopmental outcomes in children with single-ventricle circulation

OBJECTIVE

To investigate longer-term physical and neurodevelopmental outcomes of patients with hypoplastic left heart syndrome (HLHS) compared with other patients with functionally single-ventricle circulation surviving beyond the age of 10 years.

DESIGN

A retrospective, observational study from a UK tertiary centre for paediatric cardiology.

RESULTS

58 patients with HLHS and 44 non-HLHS patients with single-ventricle physiology were included. Subjective reduction in exercise tolerance was reported in 72% (95% CI 61% to 84%) of patients with HLHS and 45% (31% to 60%) non-HLHS patients. Compared with non-HLHS patients, educational concerns were reported more frequently in patients with HLHS, 41% (29% to 54%) vs 23% (10% to 35%), as was a diagnosis of a behaviour disorder (autism or attention deficit hyperactivity disorder) 12% (4% to 21%) vs 0%, and referral to other specialist services 67% (55% to 79%) vs 48% (33% to 63%).

CONCLUSIONS

Within a group of young people with complex congenital heart disease, those with HLHS are likely to have worse physical, psychological and educational outcomes.

Barriers to seeking help among children with attention deficit hyperactivity disorder in Taiwan

BACKGROUND

This study explores barriers to seeking help for children with attention deficit hyperactivity disorder (ADHD) in Taiwan.

METHODS

The caregivers (mainly mothers) of 104 children with ADHD were evaluated on an outpatient basis. The mean age of the ADHD children was 9.47 ± 1.97 years. Sociodemographic data and barriers related to seeking help were collected, including age, sex, multiple medical care seeking and parents' attitude toward the use of stimulants. The intensity of the barriers to seeking help was compared between good and/or poor compliance groups.

RESULTS

Those who took methylphenidate (MPH) regularly are less likely engage in multiple medical care seeking (P < 0.05) and are more likely to choose to seek help from a child psychiatrist as a first response to symptoms (P < 0.05). Boys with ADHD favored medical MPH treatment when seeking help. ADHD children of mothers with a higher education were more likely to refuse psychiatric treatment in the initial stage and seek alternative treatment such as sensory integration training.

DISCUSSION

There is a need to clarify how the misdiagnosis of ADHD as sensory integration dysfunction may impede seeking effective mental health care. Policy makers should enhance the understanding of parents with children with ADHD to increase treatment effectiveness and adherence.

Children diagnosed with attention deficit disorder and their hospitalisations: population data linkage study

Examine the hospital admission risk in young children who are subsequently diagnosed with attention deficit hyperactivity disorder (ADHD). We conducted a population-based, record linkage study. Records of all non-Aboriginal children under 18 years who met the DSMIV/ICD10 criteria for ADHD and prescribed stimulant medication in Western Australia between 2003 and 2007 (n = 11,902) were linked to two other health data systems-the hospital morbidity data system and the midwives notification system (MNS). The non-ADHD reference population (n = 27,304) was randomly selected from the MNS. Compared with controls, children under 4 years who subsequently were diagnosed and treated for ADHD were 70% [odds ratio (OR) 1.70; 95% confidence intervals (CI) 1.62-1.77] more likely to be admitted to hospital under 4 years of age. There was an increased risk for injury or poison (OR 1.73; 95% CI 1.59-1.88), respiratory disease (OR 1.49; 95% CI 1.40-1.59), ear disease (OR 2.03; 95% CI 1.86-2.21), infectious diseases (OR 1.68; 95% CI 1.53-1.85) and neurological conditions (OR 2.03; 95% CI 1.68-2.44). Admissions under 4 years of age for head injuries, burns, poisons, all other injuries, diseases of the tonsils and adenoids, asthma and early infections were all more common amongst children subsequently diagnosed with and treated for ADHD. There is significant early hospital morbidity for children subsequently diagnosed with ADHD. Multiple aetiologies and causal pathways need to be considered where some of these may include early infections, inflammatory conditions, epilepsy and injuries. Future studies should look at which of these conditions may be on the causal pathway or likely early markers for ADHD.

[Attention-deficit/hyperactivity disorder in childhood/adolescence and impairments associated with daily life: French data from the European Lifetime Impairment Survey]

Attention-deficit/hyperactivity disorder (ADHD) has a 3-5 % prevalence in Europe and North America. It is associated with functional impairment and can have a negative impact on social and family relationships and daily living. The experiences of children/adolescents with ADHD in Europe, as reported by parents/caregivers who completed the online Lifetime Impairment Survey (LIS), were evaluated. The LIS was conducted in France, Germany, Italy, Spain, the Netherlands, and the UK to assess the extent to which the daily lives of children/adolescents (aged<20 years) with ADHD are affected by their disorder as reported by parents/caregivers. Participants to the survey were recruited by email from the GfK Global Online Panel, which consisted of a database of 487,533 members (including 85,512 members in France). The control group comprised parents/caregivers of children/adolescents without ADHD. Treatment for ADHD, as perceived by parents/caregivers of children/adolescents with ADHD, was also reviewed. Data from France are described here. In France, 157 (79 with ADHD, 78 without ADHD) parents/caregivers completed the LIS. Median age at diagnosis was 6.0 years (mean [SD], 6.4 [3.18] years) as reported by parents/caregivers; pharmacological treatment was prescribed for 46.8 % (37/79) of children/adolescents with ADHD. Compared with the control group, ADHD was associated with significantly greater impairment across all domains studied (P<0.001), except problems in home life. General impairment scale data demonstrated that more parents/caregivers of children/adolescents in the ADHD group than the control group thought that experiences during childhood/adolescence and unhappy memories would have a negative impact on their child in adult life (29-32 % vs 9-12 %, respectively). Issues that affected school/education were associated with perceived greater impairment in the ADHD group than the control group. Several limitations should be taken into account when reviewing these data, including the lack of questionnaire validation (although developed by expert consensus). In addition, the survey was conducted online and, as such, was more likely to recruit individuals who were well-educated, computer-literate, and willing to participate in the survey. Survey participants may also have had greater awareness of ADHD and the associated symptoms and impairment, and greater motivation to seek diagnosis or treatment, than the general population. Furthermore, diagnosis of ADHD and history of diagnosis were parent-/caregiver-reported and the results may have been influenced by recall bias or subjective reporting given that the survey did not directly assess the opinions of the children/adolescents with the disorder. These data provide insights into the negative impact that ADHD imposes on all aspects of life for children/adolescents in France with the disorder. Moreover, ADHD is believed to have a negative impact later in the patient's life. Further progress is needed in France and across Europe to provide a more effective and consistent approach to the treatment of patients with ADHD and to meet the expectations regarding management and treatment for the families concerned.

Methylphenidate treatment of attention deficit hyperactivity disorder in young people with learning disability and difficult-to-treat epilepsy: evidence of clinical benefit

Purpose

To establish the efficacy and safety of methylphenidate (MPH) treatment for attention deficit hyperactivity disorder (ADHD) in a group of children and young people with learning disability and severe epilepsy.

Methods

This retrospective study systematically reviewed the case notes of all patients treated with methylphenidate (MPH) for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) ADHD at a specialist epilepsy center between 1998 and 2005. Treatment efficacy was ascertained using clinical global impressions (CGI) scores, and safety was indexed by instances of >25% increase in monthly seizure count within 3 months of starting MPH.

Key Findings

Eighteen (18) patients were identified with refractory epilepsies (14 generalized, 4 focal), IQ <70, and ADHD. Male patients predominated (13:5) and ADHD was diagnosed at a median age of 11.5 years (range 6–18 years). With use of a combination of a behavioral management program and MPH 0.3–1 mg/kg/day, ADHD symptoms improved in 61% of patients (11/18; type A intraclass correlation coefficient of CGI 0.85, 95% confidence interval [CI] 0.69–0.94). Daily MPH dose, epilepsy variables, and psychiatric comorbidity did not relate to treatment response across the sample. MPH adverse effects led to treatment cessation in three patients (dysphoria in two, anxiety in one). There was no statistical evidence for a deterioration of seizure control in this group with the use of MPH.

Significance

Methylphenidate with behavioral management was associated with benefit in the management of ADHD in more than half of a group of children with severe epilepsy and additional cognitive impairments. Eighteen percent had significant side effects but no attributable increase in seizures. Methylphenidate is useful in this group and is likely to be under employed.

Twenty years of research shows UK child development team provision still varies widely for children with disability

OBJECTIVES

To identify how services provided by child development teams (CDTs) have changed over 20 years. To what extent have major government initiatives aiming to improve the lives of children with disability and their families been implemented by teams?

DESIGN

Survey sent to every UK CDT in 2009/2010; comparison with data gathered in 1988 and 1999.

RESULTS

Ninety-four per cent (225/240) of CDTs responded; data on 242 teams were available from 1999 and 125 teams from 1988. Despite policy recommendations advocating the value of interdisciplinary team working, there was a decline in numbers of professionals working within the CDT multidisciplinary team. One-third of all teams reported a reduction in their funding over the last 5 years. However, specialist clinics provided increased. Teams reported patchy adoption of national initiatives designed to improve provision. Transition services were underdeveloped.

CONCLUSIONS

This comprehensive survey of UK CDT service provision, as well as national studies of the healthcare experience of families with a disabled child, shows that improvements in provision are required.

A modeled economic evaluation comparing atomoxetine with stimulant therapy in the treatment of children with attention-deficit/hyperactivity disorder in the United Kingdom

OBJECTIVE

To estimate the cost-effectiveness of atomoxetine for children with attention-deficity/hyperactivity disorder (ADHD) in the United Kingdom compared with current alternatives.

METHODS

An economic model with Markov processes was developed to estimate the costs and benefits of atomoxetine versus other current ADHD treatment options. The model evaluated atomoxetine in five patient subgroups according to treatment history and the existence of comorbidities precluding stimulant medication. The incremental cost per quality-adjusted life-year (QALY) was calculated for atomoxetine treatment algorithms compared with comparator algorithms. The Markov process incorporated 18 health states, representing a range of outcomes across all treatment options included in the algorithms. Utility values were derived from a survey of 83 parents of children with ADHD. The effectiveness and safety aspects of the treatment options were based on a thorough review of controlled clinical trials and other clinical literature, and validated by international experts. Costs and outcomes were estimated using Monte Carlo simulation over a 1-year duration, with costs estimated from the perspective of the National Health Service in England and Wales.

RESULTS

For stimulant-naive patients, the incremental cost per QALY gained for the atomoxetine algorithm compared with immediate-release methylphenidate hydrochloride (MPH) was pound 15,224 ( pound 13,241 compared with extended-release MPH). In the stimulant-exposed populations, the incremental cost per QALY for the atomoxetine algorithm was between pound 14,169 and pound 15,878. For patients contraindicated for stimulant therapies, the incremental cost per QALY was pound 11,523 and pound 12,370 for stimulant-naive and stimulant-exposed populations, respectively.

CONCLUSION

The economic evaluation showed atomoxetine is an effective alternative across a range of ADHD populations and offers value-for-money in the treatment of ADHD.

The provision and nature of ADHD services for children/adolescents in the UK: results from a nationwide survey

The Attention Deficit Hyperactivity Disorder (ADHD) Observational Research in Europe (ADORE) project aims to describe the relationship between prescribed treatment regimen and quality of life in ADHD patients across Europe over a 2-year period. As an adjunct to the ADORE study, a survey was conducted to assess the availability and range of ADHD treatment services in the UK. A questionnaire was developed to assess service provision at 20 UK ADORE sites. These data give information regarding the assessment process (i.e. the formal psychological instrumentation used), whether information is requested from schools, and what other medical and allied health care specialities are frequently involved in the diagnosis. Results of the survey provide an important insight into the ADHD-related services provided by ADORE centres, as well as highlighting the availability and limitations of such services.

Societal costs and quality of life of children suffering from attention deficient hyperactivity disorder (ADHD)

BACKGROUND

The impact of attention deficit hyperactive disorder (ADHD) in the Netherlands on health care utilisation, costs and quality of life of these children, as well as of their parents is unknown.

OBJECTIVE

The aim of this study was to assess the direct medical costs of patients suffering from ADHD and their quality of life as well as the direct medical costs of their mothers.

STUDY DESIGN

We selected a group of 70 children who were being treated by a paediatrician for ADHD based on the DSM-IV diagnostic criteria for ADHD. For comparison's sake, we also included a non-matched group of 35 children with behaviour problems and 60 children with no behaviour problem from a large school population-based study on the detection of ADHD. We collected information on the health care utilisation of the children applying the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness' (TiC-P). Their health related quality of life was collected by using the Dutch 50-item parent version of the Child Health Questionnaire (CHQ PF-50). Measurements were at baseline and at 6 months. Subsequently, we collected data on the health utilisation of the mothers and their production losses due to absence from work and reduced efficiency.

RESULTS

The mean direct medical costs per ADHD patient per year were euro 2040 or euro 1173 when leaving out one patient with a long-term hospital admission, compared to euro 288 for the group of children with behaviour problems and euro 177 for the group of children with no behaviour problems. The direct medical costs for children who had psychiatric co-morbidities were significantly higher compared to children with ADHD alone. The mean medical costs per year for the mothers of the ADHD patients were significantly higher than for the mothers of the children with behaviour problems and the mothers of children with no behaviour problems respectively euro 728, euro 202 and euro 154. The physical summary score showed no significant differences between the groups. However, the score on the Psychosocial Summary Score dimension was significantly lower for ADHD patients compared to the scores of the children in the two other samples. The mean annual indirect costs due to absence from work and reduced efficiency at work were euro 2243 for the mothers of the ADHD patients compared to euro 408 for the mothers of children with behaviour problems and euro 674 for the mothers of children with no behaviour problems.

CONCLUSION

Our study showed that the direct medical costs of ADHD patients were relatively high. Additionally, our study indicated that ADHD appears to be accompanied by higher (mental) health care costs for the mothers of ADHD patients and by increased indirect costs for this group.

Integrative neuroscience approach to predict ADHD stimulant response

Despite high rates of prescription, little is known about the long-term consequences of stimulant medication therapy for attention-deficit hyperactivity disorder (ADHD) sufferers. Historically, the clinical use of stimulants for ADHD has been based on trial and error before optimal therapy is reached. Concurrently, scientific research on the mechanism of action of stimulants has influenced neurobiological models of ADHD, but has not always informed their prescription. Whilst the two main stimulant types (methylphenidate and dexamphetamine) have numerous similarities, they also differ (slightly) in mechanism and possibly individual response. A further issue relates to differences in cost and availability compounded by the expectation for stimulants to be effective in ameliorating a broad spectrum of ADHD-related symptoms. Thus, there is an increasing need for treating clinicians to prescribe not only the most effective drug, but also the most appropriate dose with the associated release mechanism and schedule for each ADHD patient presented. In this regard, the field is witnessing an emergence of the personalized medicine approach to ADHD, in which treatment decisions are tailored to each individual. This shift requires a new approach to research into treatment response prediction. Given the heterogeneity of ADHD, a profile of information may be required to capture the most sensitive predictors of treatment response in individuals. These profiles will also benefit from the integration of data from clinical rating scales with more direct measures of cognition and brain function. In conclusion, there is a need to establish a more robust normative framework as the baseline for treatment, as well as diagnostic decisions, and as discussed, the growth of integrated neuroscience databases will be important in this regard.

Who receives a diagnosis of attention-deficit/ hyperactivity disorder in the United States elementary school population?

OBJECTIVE

To investigate factors that are associated with the probability of attention-deficit/hyperactivity disorder (ADHD) diagnosis among U.S. elementary school children, including child, family, school, and policy factors.

METHODS

Logistic regression was used to estimate relative risks associated with independent variables using a nationally representative sample of 9278 children in the 2002 follow-up of the Early Childhood Longitudinal Survey-Kindergarten Cohort. Most children in the sample were in third grade at this point. Previous ADHD diagnoses by professionals were reported by parent respondents.

RESULTS

A total of 5.44% of children were reported to have received an ADHD diagnosis. Girls, black children, and Hispanic children were less likely to have the diagnosis even after controlling for other characteristics. Living with one's biological father was negatively associated with ADHD diagnosis. We also found regional variation in diagnosis with the western region of the United States having significantly lower instances of ADHD cases. Higher diagnosis rates were associated with having an older teacher, and lower rates were associated with having a white teacher, relative to a nonwhite teacher. In schools that were subject to stricter state-level performance accountability laws, we found higher odds of ADHD diagnoses, but we found no differences associated with larger class sizes or the presence of state laws that restrict school personnel from discussing ADHD treatment options with parents.

CONCLUSIONS

ADHD diagnosis is likely to be influenced by a child's social and school environment as well as exogenous child characteristics. Concerns that increased pressures for school performance are associated with increased ADHD diagnoses may be justified.

Attention-deficit/hyperactivity disorder: an overview of the etiology and a review of the literature relating to the correlates and lifecourse outcomes for men and women

This paper provides a summary of the current conceptualization of what AD/HD is, and its etiology, and then reviews some of the recent literature on the correlates and lifecourse outcomes for individuals diagnosed with Attention-Deficit/Hyperactivity Disorder (AD/HD). The intention is to synthesize that which is known, and to identify important gaps in the literature and knowledge base, which secondary analysis of prospective large-scale longitudinal cohorts, tracking individuals from birth to adulthood, could help to fill. This review highlights the fact that such datasets are rare and that their analysis offers important opportunities for advancing knowledge, particularly of the adult outcomes of childhood AD/HD.